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surgery > Hernias > Flashcards

Hernias Flashcards

1
Q

What is a hernia?

A

Protrusion of a viscus either in part or in whole from its enclosed cavity, through a potential space or anatomical weak point

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2
Q

All hernias are made up of
The mouth
The neck
The body
The fundus

Except?

A

Incisional hernia
Epigastric hernia

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3
Q

Hernia could also be classified according to its accesibility into

A

INTERNAL HERNIAS
1. Tentorial hernias (in the brain)
2. Diaphragmatic hernias
3. Stammer’s (Patterson’s) hernia – Mesenteric hernia
4. Paraduodenal Hernias

EXTERNAL HERNIAS
VENTRAL HERNIAS
1.Groin hernias
Femoral hernia
Inguinal Hernias
2. Umbilical Hernias
Supra-umbilical hernia
Infra-umbilical hernia
3. Incissional hernias (via previous scars)
3. Epigastric Hernia

LATERAL HERNIAS (LOSS)
1. Lumbar Hernias
2. Obturator Hernias
3. Sciatic hernias
4. Spigelian hernias

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4
Q

Briefly discuss the aetiology of hernias

A

A. WEAKENED ABDOMINAL WALL
Congenital
1. Patent processus vaginalis
2. Omphalocoeles
3. Weakened internal ring seen in Marfan’s syndrome, Prune-belly syndrome
4. Sites of vascular penetration causing pre-peritoneal hernia

Acquired
1. Infection e.g omphalitis, wound infection
2. Obesity
3. Ageing
4. Injury to motor nerves

B. INCREASED INTRA ABDOMINAL PRESSURE
1. Chronic Cough eg COPD
2. Bladder outlet obstruction eg stricture, BPH
3. Heavy manual work
4. Pregnancy – Frequent/multiple pregnancies
4. Ascites/Abdominal tumours etc

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5
Q

Discuss the natural history of hernias

A

1) Hernias starts as Reducible hernia
2) Then becomes Irreducible:- This is due to incarceration.
3) Obstructed Hernia:- No venous return but arterial flow. Mass becomes bigger, painful, irreducible but viable.
4) Strangulated hernia:- Both venous and arterial supplies are cut-off. Contents become ischemic, putrfy and gangrene sets in.
5) Perforated hernia:- If strangulated hernia is left untreated, it can perforated to the exterior (enterocutaneous fistula) or to the interior (peritonitis)

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6
Q

Inguinal hernias are the most commonly strangulated hernias.

True or False?

A

False

Femoral hernias strangulate more often than inguinal hernias

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7
Q

Indirect hernias strangulate more commonly that direct hernias.

True or False

A

True

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8
Q

Small bowl strangulation is commoner on the right side than on the left side

True or false

A

True

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9
Q

List the possible causes of incarceration in hernias

A

1) impacted faces
2) adhesions
3) bulky distended loops of bowel
4) sliding hernias

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10
Q

For indirect inguinal hernias, where does the herniating part enter the inguinal canal from?

A

Internal ring (deep inguinal ring)

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11
Q

For indirect inguinal hernias, where does the herniating part exit the inguinal canal from?

A

Superficial ring (superficial inguinal ring)

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12
Q

What is the commonest type of hernia in both males and females?

A

Inguinal hernia

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13
Q

For males Indirect hernias are more common on the right than on the left

True or False

A

True

Because if the late descent of the right testis

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14
Q

What are the boundaries of the inguinal canal

A

2(MALT)
Roof:- 2 Muscles
i. Internal oblique
ii. Transversus abdominis
iii. Transversalis fascia
Anterior wall:- 2 Aponeurosis
i. Aponeurosis of external oblique
ii. Aponeurosis of internal oblique
Floor:- 2 Ligaments
i. Inguinal ligament
ii. Lacunar ligament
Posterior wall:- 2
i. Transversalis fascia
ii. Conjoint Tendon

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15
Q

For direct hernias, herniating contents enter the inguinal canal through?

A

Posterior wall of the inguinal canal (Transversalis fascia) through the Triangle of Hasselbach

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16
Q

Direct hernias are more common on the left than on the right

True or False

A

False

They have equal distribution

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17
Q

What lies anterior to a direct hernia

A

Spermatic cord

In indirect hernias, the sac lies (antero-)medial to the cord.

In direct hernias, the sac lies behind the cord with the inferior epigastric artery lying lateral to the neck.

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18
Q

What lies superior to a direct hernia

A

Epigastric artery

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19
Q

Where is the opening of the inguinal canal located and what is its clinical importance?

A

Location:- Midpoint of the inguinal ligament. This is the midpoint from the ASIS to the pubic tubercle

Clinical importance:- On examination, if you perform a ring occlusion (plugging the internal ring with your finger) and there is still herniation on coughing = Direct hernia until proven otherwise.

20
Q

What is the mid-inguinal point and what is the clinical importance

A

This is the midpoint between the ASIS and the pubic symphysis.

Clinical importance:- This is where the femoral pulse is checked.

21
Q

Direct inguinal hernias are common in females

True or False

A

False

They are rare

22
Q

What is a *PANTALOON HERNIA**

A

An inguinal hernia in which part of the sac is indirect (lateral to inferior epigastric) while another comes direct (medial to inferior epigastric) through the triangle of Hasselbach.

Having the inferior epigastric artery in-between the two is called

23
Q

What is an incomplete hernia

A

Groin Hernias that remain above the groin crease

24
Q

What is a Complete hernia.

A

Hernia exits the external ring and enters the scrotum (or labium majus). inguino-scrotal or inguino-labial

25
Q

What is a bubonocoele

A

An incomplete hernia that is limited to the inguinal canal

26
Q

What is a funinculocoele

A

A hernia has traversed the external ring and lies just above the pubic tubercle – on the spermatic cord

27
Q

What is a pro-peritoneal hernia

A

It is an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie between transversalis fascia and peritoneum

Lies between a fascia and peritoneum

28
Q

What is an interstitial hernia

A

It is an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie between transversalis fascia and transverse abdominis muscle

Lies between a fascia and muscle

29
Q

What is an interparietal hernia

A

It is an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie between
internal oblique or transversus abdominis or even external oblique

Lies between 2 muscles

30
Q

To avoid recurrence of a hernia, what do you do during repair?

A

Tightening the ring by Lyttle’s stitch or Plug and patch technique

31
Q

What are the boundaries of the hasselbach’s triangle

A

•Medially by the lateral border of the rectus sheath,
•Laterally by the inferior epigastric artery
•Inferiorly (base) by the Inguinal ligament.

32
Q

How do you examine a hernia

A

1) Confirm the presence of the hernia:- palpable cough; Vissible cough impulse.

2) Determine whether it inguinal or femoral hernia:- The neck of an inguinal hernia is above the inguinal ligament.

3) Determine whether it is a direct or indirect hernia:- Perform a ring occlusion (block). Most complete inguinal hernias are indirect.

33
Q

List the differential diagnosis for a hernia

A
  • Femoral Hernia
  • Hydrocoeles
  • Malgaignes’ bulges
  • Undescended and ectopic testes
  • Lymphadenopathy
  • Saphena varix, femoral artery aneurysm
  • Lipoma
  • Psoas Abscess
34
Q

What are the treatment options for a hernia

A

● Herniotomy
● Lyttle’s procedure
● Repair of Defect:
(i)Herniorhapphy
(ii)Hernioplasty
(iii)Laparoscopic

35
Q

What are the Indications for Laparoscopic Repair

A

●Recurrent hernia
●Bilateral hernia
●Need for speedy return to work

36
Q

What are the contraindications for laparoscopic repair?

A

• Huge inguino – Scrotal hernia
• Irreducible hernias
• Lower midline incissions
• Previous pre-peritoneal surgery like prostatectomy

37
Q

What are the Post-operative complications of Hernia repair

A

Early
Pain
Urinary retension
Scrotal Haematoma
Vasectomy

Late
Wound infections
Testicular infarction
Transient testicular orchitis
Post-operative Hydrocoele
Impotence
Recurrence

38
Q

What are the Causes of hernia Recurrence

A

●Size and duration of the hernia
●Age of the patient. Recurrence is higher over 48yrs
●Sliding hernias recur more
●Over-looked Pantaloon hernia
●Technical details – like suture material. Tension repairs recur earlier.
●Persistent increase in abdominal pressure
●Wound infection
●Sex. Recurrence is less in women

39
Q

Femoral hernia affects men more than women.

True or false?

A

False

Femoral hernia affects women more than men

40
Q

Where is the entry point for femoral hernia

A

Femoral ring

41
Q

List the The boundaries of the Femoral canal

A

●Anteriorly – Inguinal ligament
●Posteriorly – Pectineal fascia (Cooper’s ligament)
●Medially – lacunar ligament
●Laterally – Femoral Vein.

42
Q

The sax in femoral hernia exits from the femoral canal via the?

A

Fossa ovalis

43
Q

Differential diagnosis for femoral hernia

A

Inguinal hernia
Femoral vein aneurysm
Lymph node enlargement
Lipoma

44
Q

Treatment modality for femoral hernia

A

●Low operation of Lockwood
●High operations:
(i) Lotheisein inguinal approach
(ii) extra peritoneal approach

45
Q

What are the complications of hernia reduction?

A

●Reduction-en-mass. This is return of unreduced hernia contents together with the sac into the peritoneal cavity. If this was done by patient it is called “auto reduction-en-masse”.
● Reduction of de-vitalised tissue into the peritoneal cavity.
● Bowel may develop stricture at point of strangulation

46
Q

Is resuscitation needed before surgery for hernia repair?

A

Yes

Resuscitate before Surgery
•N/G tube, Urinary catheter, Antibiotics,
•Adequate fluid input/output
•Adequate analgesia
•Monitor vital signs: BP, Pulse, RBS, Sp02
•Blood tests and transfusion

surgery (29 decks)

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